Vaccination recommendations for adults receiving biologics and oral therapies for psoriasis and psoriatic arthritis: Delphi consensus from the medical board of the National Psoriasis Foundation.

BACKGROUND: For psoriatic patients who need to receive nonlive or live vaccines, evidence-based recommendations are needed regarding whether to pause or continue systemic therapies for psoriasis and/or psoriatic arthritis. OBJECTIVE: To evaluate literature regarding vaccine efficacy and safety and to generate consensus-based recommendations for adults receiving systemic therapies for psoriasis and/or psoriatic arthritis receiving nonlive or live vaccines. METHODS: Using a modified Delphi process, 22 consensus statements were developed by the National Psoriasis Foundation Medical Board and COVID-19 Task Force, and infectious disease experts. RESULTS: Key recommendations include continuing most oral and biologic therapies without modification for patients receiving nonlive vaccines; consider interruption of methotrexate for nonlive vaccines. For patients receiving live vaccines, discontinue most oral and biologic medications before and after administration of live vaccine. Specific recommendations include discontinuing most biologic therapies, except for abatacept, for 2-3 half-lives before live vaccine administration and deferring next dose 2-4 weeks after live vaccination. LIMITATIONS: Studies regarding infection rates after vaccination are lacking. CONCLUSION: Interruption of antipsoriatic oral and biologic therapies is generally not necessary for patients receiving nonlive vaccines. Temporary interruption of oral and biologic therapies before and after administration of live vaccines is recommended in most cases.

Management of Psoriasis With Topicals: Applying the 2020 AAD-NPF Guidelines of Care to Clinical Practice.

Topical medications have high utility in the treatment of psoriasis because of their localized effect and ability to be used as both monotherapy and adjunctive therapy. The American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF) published guidelines in 2020 regarding the management of psoriasis with topical therapies. These guidelines are a framework that assist clinicians treating psoriasis patients with topical agents including steroids, calcineurin inhibitors (CNIs), vitamin D analogues, retinoids (tazarotene), emollients, keratolytics (salicylic acid), anthracenes (anthralin), and keratoplastics (coal tar). This review presents these evidence-based recommendations in a form that dermatologists can readily apply to their clinical practice. The selection of an appropriate topical therapy, effective combination therapies, duration of use, and adverse events are addressed.

Who sees you matters: a population study examining topical corticosteroid prescribing patterns between primary care providers and dermatologists for atopic dermatitis.

BACKGROUND: Many patients with atopic dermatitis seek care from both primary care physicians and dermatologists. However, little is known regarding topical corticosteroid prescribing patterns among these specialties. OBJECTIVE: We sought to determine if differences exist in topical corticosteroid prescribing patterns among dermatologists, family medicine physicians, and internal medicine physicians. METHODS: We conducted a population-based, cross-sectional analysis using data from the U.S. National Ambulatory Medical Care Survey from 2006 to 2016. RESULTS: Compared to dermatologists, internal medicine physicians were 22 times less likely to prescribe a topical corticosteroid for atopic dermatitis (52.2% versus 5.1%, p = .001; adjusted OR 0.045, 95%CI 0.007-0.277). There was not a statistically significant difference in the rate of topical corticosteroid prescriptions for atopic dermatitis between family medicine physicians and dermatologists (39.1% vs. 52.2%, p = .27; adjusted OR 0.468, 95%CI 0.174-1.257). Family medicine physicians had a higher rate of prescribing topical corticosteroids for atopic dermatitis than internal medicine physicians (39.1% vs. 5.1%, p = .002). LIMITATIONS: Severity of atopic dermatitis was not assessed. CONCLUSIONS: Atopic dermatitis patients seen by internal medicine physicians are much less likely to receive topical corticosteroid prescriptions as compared to those seen by dermatologists.

Language proficiency and biologics access: a population study of psoriasis patients in the United States.

BACKGROUND: Language proficiency plays an important role in healthcare choices and access. Differences in access to biologic medications exist, but it is unknown how much English proficiency influences access in US psoriasis patients. OBJECTIVE: To compare biologic medication use for psoriasis patients with differing English proficiency levels. METHODS: Population study of US psoriasis patients using the 2013-2017 Medical Expenditure Survey. RESULTS: Among a total of 4,470,820 US psoriasis patients (weighted), 4,028,119 (90.1%) had perfect English proficiency, and 442,700 (9.9%) had less than perfect English proficiency. Among the total population, 422,523 (9.5%) had access to biologics. Among those who received biologics, 411,411 (97.4%) of those had perfect English proficiency, and 11,112 (2.6%) of those had less than perfect English proficiency. Multivariate logistic regression found that patients with less than perfect English proficiency were significantly less likely to have access to biologics [OR 0.015 (95% CI: 0.001-0.179); p = .002], after adjusting for insurance status, income, education, healthcare utilization, and other sociodemographic and clinical factors. LIMITATIONS: Psoriasis disease severity not specified. CONCLUSIONS: Psoriasis patients with low English proficiency are significantly less likely to receive biologics than those with high English proficiency. Those with higher English proficiency are 61 times more likely to access biologics.

Use of systemic therapies for psoriasis in the COVID-19 era.

BACKGROUND: In late 2019 a viral pneumonia began to spread across the world. The viral disease, COVID-19, is now officially a pandemic, causing concern for the potential risk of systemic therapies for patients with psoriasis. OBJECTIVE: The purpose of this review is to analyze what is currently known about COVID-19 in regard to the safety of systemic treatment, and to provide guidelines for use in psoriasis during this pandemic. METHODS: Review of guidelines from various dermatologic regulatory bodies regarding the use of systemic medications during the COVID-19 pandemic was performed and summarized. RESULTS: The AAD, NPF and IPC are in agreement regarding their recommendation that patients with active COVID-19 infection should discontinue any biologic therapy. CONCLUSION: Patients with active COVID-19 infections should discontinue systemic treatment for psoriasis. Patients with risk factors should discuss continuing treatment on a case by case basis.

Review and analysis of biologic therapies currently in phase II and phase III clinical trials for atopic dermatitis.

Biologic medications are recent advances that have clinical significance in the treatment of moderate-to-severe AD. A systemic literature review was performed to examine the efficacy and safety of biologic therapies currently in phase II and phase III of clinical trials for moderate-to-severe AD. Our team searched the databases, PubMed, Google Scholar, and ClinicalTrials.gov, on September 2019 for studies pertaining to the use of biologic drugs in AD. Key words included each drug (lebrikizumab, tralokinumab, fezakinumab, etokimab, nemolizumab, tezepelumab, and GBR 830) or 'biologic drugs' or 'immunotherapies' combined with 'atopic dermatitis.' References within retrieved articles were also reviewed to identify potentially missed studies. A total of 19 articles were included in this review. Lebrikizumab, tralokinumab, fezakinumab, nemolizumab, and GBR 830 lead to statistically significant improvements in disease severity and multiple endpoint outcome scores. Tezepelumab and etokimab, however, did not demonstrate statistically significant changes in primary outcome endpoints. Further assessment of tezepelumab and etokimab are needed to assess their safety and efficacy in patients with moderate-to-severe AD. Tralokinumab, lebrikizumab, fezakinumab, nemolizumab, and GBR 830 are effective treatment options for adults with moderate-to-severe AD, but further large-scale studies are needed to confirm their efficacy as monotherapy in children with moderate-to-severe AD.

Clinical management of psoriasis patients during the COVID-19 pandemic.

Psoriasis is a systemic immune-mediated inflammatory disease that requires consistent treatment and follow-up. Given that COVID-19 will persist in the coming years, dermatologists need to adjust their practices accordingly to care for their patients, particularly psoriasis patients managed with systemic therapies. We provide guidelines for optimizing care for psoriasis patients, including considerations for medication management, lifestyle adjustments, and utilization of telemedicine.

Differences in health care resource utilization and costs for keratinocyte carcinoma among racioethnic groups: A population-based study.

BACKGROUND: As the United States becomes more diverse, determining differences in health care utilization and costs in the management of skin cancers is fundamental to decision-making in health care resource allocation and improving care for underserved populations. OBJECTIVE: To compare health care use and costs among non-Hispanic White, Hispanic White, and non-Hispanic Black patients with keratinocyte carcinoma. METHODS: A nationwide cross-sectional study was performed using Medical Expenditure Panel Survey data from 1996 to 2015. RESULTS: Among 54,503,447 patients with keratinocyte carcinoma (weighted) over a 20-year period, 53,134,351 (97%) were non-Hispanic White; 836,030 (1.5%) were Hispanic White; and 170,755 (0.3%) were non-Hispanic Black. Compared to non-Hispanic White patients, Hispanic White patients had significantly more ambulatory visits per person per year (5.4 vs 3.5, P = .003). Compared to non-Hispanic White patients, non-Hispanic Black patients had significantly more ambulatory visits (13.1 vs 3.5, P = .027) and emergency department visits (2.3 vs 1.1, P < .001), and incurred significantly higher ambulatory costs ($5089 vs $1131, P = .05), medication costs ($523 vs $221, P = .022), and total costs per person per year ($13,430 vs $1290, P = .032). LIMITATIONS: Data for squamous cell carcinomas and basal cell carcinomas are combined. CONCLUSIONS: Keratinocyte carcinoma was more costly to treat and required more health care resources in non-Hispanic Black and Hispanic White patients than in non-Hispanic White patients.

Comparison of Guidelines for the Use of Interleukin-17 Inhibitors for Psoriasis in the United States, Britain, and Europe: A Critical Appraisal and Comprehensive Review.

BACKGROUND: Interleukin (IL)-17 inhibitors are a newer class of biologic used to treat patients with moderate-to-severe plaque psoriasis and psoriatic arthritis. OBJECTIVE: We compared evidence-based clinical practice guidelines (CPGs) from leading dermatological organizations for the use of IL-17 inhibitors in psoriasis. METHODS: Guidelines from the Joint American Academy of Dermatology-National Psoriasis Foundation (AAD-NFP) Guidelines, British Association of Dermatologists guidelines (BAD), and European S3 group (ES3) were all reviewed and compared. RESULTS: This analysis revealed significant overlap in the recommendations made by experts from each CPG. However, our review highlights differences in routine laboratory recommendations and the relative and absolute contraindications to use with IL-17 inhibitors. CONCLUSION: IL-17 inhibitors are an effective treatment option for psoriasis. This analysis and review of guidelines for IL-17 inhibitor use highlights the consensus in treatment protocols and areas of disagreement between CPGs.

Translating the 2019 AAD-NPF Guidelines of Care for Psoriasis With Attention to Comorbidities.

In April 2019, the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF) released a set of guidelines regarding the management of psoriasis with a focus on its extracutaneous manifestations-comorbidities, mental health, psychosocial wellness, and quality of life (QOL). These guidelines provide the most up-to-date evidence on the screening and treatment recommendations for these disease comorbidities. The purpose of this review is to present the recommendations in a form that can be easily applied in clinical practice.

Comparison of guidelines for the use of Ustekinumab for psoriasis in the United States, Europe, and the United Kingdom: A critical appraisal and comprehensive review.

The aim of this review is to compare and contrast evidence-based clinical practice guidelines from global dermatological organizations for the use of ustekinumab in psoriasis. Clinical practice guidelines from the American Academy of Dermatology, National Psoriasis Foundation, British Association of Dermatologists, and European S3 were reviewed and compared. Practice guidelines from the three dermatological organizations are similar with regards to treatment dosage and initiation but differ in their recommendations for baseline screening and interval laboratory monitoring, treatment in patients undergoing surgery or receiving live vaccines, and treatment contraindications. Ustekinumab is an effective and well-tolerated systemic treatment for patients with psoriasis and should be considered in the line of therapy that dermatologists discuss with their patients. Consideration should be given to evidence-based practice guidelines of global dermatology organizations to effectively guide treatment decisions in patients with psoriasis.

Translating the 2020 AAD-NPF Guidelines of Care for the Management of Psoriasis With Systemic Nonbiologics to Clinical Practice.

In 2020, the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF) released a set of guidelines for the management of psoriasis in adults with systemic nonbiologic therapies, including acitretin, apremilast, cyclosporine, fumaric acid esters, methotrexate, and tofacitinib. This review addresses dosing, efficacy, toxicity, drug-related interactions, and contraindications alongside evidence-based treatment recommendations for each systemic therapy. Important considerations for treatment such as drug selection, initiation of therapy, drug monitoring, and patient management also are discussed. Physicians are encouraged to use these recommendations to guide treatments based on individual patient needs and disease characteristics.

Differences in Depression and Distress Between Acne Patients on Isotretinoin vs Oral Antibiotics.

BACKGROUND: Little is known regarding differential effects of systemic anti-acne treatments on mental health. OBJECTIVE: To determine whether differences exist in mental health outcomes between acne patients treated with isotretinoin versus oral antibiotics (doxycycline, minocycline, or tetracycline). METHODS: Population study utilizing the 2004-2017 Medical Expenditure Panel Survey. Depressive symptoms were assessed using Patient Health Questionnaire 2 (PHQ-2); psychological distress was measured by the Kessler 6-Item Psychological Distress Scale (K6). Acne patients completed both the PHQ-2 and K6 during treatment with isotretinoin or oral antibiotics. Lower scores on both measures indicate better mental health outcomes. RESULTS: After adjusting for socio-demographic characteristics, patients on isotretinoin had fewer depressive symptoms than patients on oral antibiotics, as measured by mean PHQ-2 scores (isotretinoin 0.280 vs oral antibiotics 0.656, difference=0.337, P<0.01). The adjusted comparison also showed patients on isotretinoin had less psychological distress than patients on oral antibiotics, as measured by K6 scores (isotretinoin 2.494 vs oral antibiotics 3.433, difference=0.759, P=0.043). LIMITATIONS: No direct assessment of acne severity. CONCLUSION: Acne patients on isotretinoin experienced less depressive symptoms and psychological distress as compared to oral antibiotics. J Drugs Dermatol. 2021;20(2):172-177. doi:10.36849/JDD.5559.

Review of treatments for generalized pustular psoriasis.

BACKGROUND: Generalized pustular psoriasis (GPP) is an uncommon variant of psoriasis that is characterized clinically by sterile pustule formation superimposed over inflamed, erythematous skin. METHODS: In June 2019, we conducted a systematic search of the PubMed Medline database using the keywords 'pustular psoriasis' and 'treatment'. RESULTS: First-line treatment for the condition consists of established therapies, such as acitretin, cyclosporine, methotrexate, and infliximab. Several medications targeting IL-17 or IL-23 have also emerged recently with drugs such as ixekizumab, secukinumab, brodalumab, guselkumab, and ustekinumab having shown some efficacy. CONCLUSIONS: This review highlights the research in support of common treatments of GPP, including classically used medications and newer monoclonal antibodies, and addresses the continued need for high quality studies regarding treatments for this condition.